Recent studies have shown that blepharitis increases in incidence with age and that in patients preparing to undergo cataract surgery, up to 60% have mild to moderate symptoms of blepharitis.1 A healthy ocular surface is critical to successful surgery. The tear film, which can be compromised by the surgery itself, needs to be optimized to enhance recovery and visual outcomes. Blepharitis, which impacts quality of life and vision, can compromise the results of your premium IOL patients, leaving them less than satisfied with their surgery.

Case study

The detrimental impact of blepharitis on visual outcome after premium IOL placement was easily discernible in a recent patient. The patient had bilateral ReSTOR intraocular lenses (Alcon, Fort Worth, Texas) placed by a different surgeon three months previously and came to me complaining that she couldn't see. Her uncorrected visual acuity (UCVA) was 20/20-25 and J1 in each eye, she had a very low refractive error, all the biometry was correct, and it appeared that the surgery had been successful. However, the patient complained that her vision seemed to fluctuate moment to moment, was poor in dim lighting situations, and she never seemed to have any distinct clarity. On the contrast chart she could make out letters but there was a little bit of ghosting or smear around the edges.
While these could all be considered typical issues with multifocal lenses, one of the first signs of ocular surface disease is that visual acuity in real-life settings doesn't correspond with patients' UCVA when tested in the clinic. Instead of suggesting a lens exchange, I did further exams and found that this patient had a very fast tear break-up time and significant meibomian gland disease, a form of blepharitis. Corneal topography demonstrated a fair amount of irregular astigmatism, and taking topography at different time points gave me different images due to the rapid tear break-up time. My first order of business was to treat the ocular surface disease. I prescribed warm compresses twice a day and AzaSite (azithromycin, Inspire Pharmaceuticals, Durham, N.C.) once a day for a week. In order to jump start the results and give the patient more immediate relief, I also prescribed the topical steroid Lotemax (loteprednol, Bausch & Lomb, Rochester, N.Y.) twice a day and asked her to come back in two weeks. As the patient didn't manifest a lot of facial rosacea, I didn't start her on systemic antibiotics. After two weeks, the patient felt her vision was improving, with the remaining problems more severe in the morning. Blepharitis typically impacts vision more in the morning, whereas dry eye typically impacts vision in the late afternoon or evening as the tear film evaporates throughout the day.
The short-term steroid had achieved the goal of treating the acute inflammation and was discontinued, and I continued focusing on the underlying disease. I continued treating the patient with AzaSite and warm compresses for two additional weeks, after which point she reported that her vision was 100% better. Images were much more distinct, there was no more ghosting, and the fluctuation throughout the day had been eliminated completely. Like hypertension, blepharitis is a long-term, chronic condition, and management of the symptoms is ongoing. For the next year, the patient will continue with warm compresses twice a day and AzaSite once a day for the first week of every month. After that point we will reassess treatment requirements.
The patient came to me frightened, thinking her eyes were permanently damaged from the surgery when in fact the surgery was perfect, but her visual results were being compromised by meibomian gland disease. By treating the blepharitis, we were able to give her the results she sought and avoid a risky surgical intervention.

Diagnosis

When mild, blepharitis and meibomian gland disease can be easily overlooked by physicians. Epidemiologic data on the prevalence of blepharitis is lacking and this, combined with a tendency by physicians to neglect examination of the eyelids and adnexa, leads to under-diagnosis of the disease.
There are several signs to indicate a possibility of blepharitis that are easily spotted if the physician is aware of them. Upon first meeting with a patient, the physician will notice if the patient has rosacea or rhinophyma (severely enlarged nose), as both of these are strong indicators of the possibility of blepharitis. When getting an oral history from the patient, the symptoms associated with blepharitis include fluctuating vision, light sensitivity, itching and/or red eyes, and eye discomfort in the morning. The presence of any of these symptoms indicates that the tear film needs to be analyzed, and a good tear film starts with the eye lids.
When examining the lid architecture, notching of the lid margin and loss of eye lashes are strong indicators of blepharitis. Finally, under the slitlamp, atrophy of the meibomian gland will be visible and thick, toothpaste-like secretions, and foamy tear film will indicate a critical situation.

Treating blepharitis first

The case study above is not an infrequent occurrence in my practice. When ocular disease is not managed properly pre-op, it becomes a much more significant problem post-op. While it can be treated and managed after the fact, patients come away from their surgery with a less-than-enthusiastic response. They often feel that the blepharitis should have been recognized and treated beforehand to spare them the concern, hassle, and disappointment post-surgery. Premium IOL patients in particular have invested more in their surgeries and are expecting excellent visual results, and blepharitis prevents them from achieving those results. Fortunately, more and more surgeons are paying attention to ocular surface diseases and treating them and with new treatment options, a treatment response will take only a couple of weeks.
Azithromycin ophthalmic solution alters the lipid composition in the eye, improving fluidity of the meibomian gland secretions.2 Clinical studies show that using azithromycin ophthalmic solution in addition to warm compresses, as compared to using warm compresses alone, brings greater improvement in meibomian gland plugging, meibomian gland secretions, and eyelid redness, in additional to overall symptomatic relief.3 The rapid improvements are both felt by the patient and observed clinically. While previous treatment options required months to treat blepharitis and restore the ocular surface, azithromycin ophthalmic solution allows results to be seen in a short time period. It is now possible to start blepharitis treatment immediately and schedule surgery two weeks out. In that amount of time symptoms will be sufficiently controlled to complete surgery successfully.
A high percentage of my cataract patients manifest blepharitis. Thus I have everyone use topical azithromycin once a week for one week before surgery. I find it an excellent way to sterilize the lid pre-surgery and prepare the ocular surface. Not only does this reduce the incidence of endophthalmitis, it also works as a general anti-inflammatory, speeding post-op recovery and quality of vision.

Conclusion

The goal of all surgeons is to give their patients the best results possible and thus to have a satisfied patient. Looking for blepharitis and aggressively treating it before surgery results in patients who are happy with their premium IOL surgical outcome and the investment in time and resources they've made in their vision.